Consolidated CDA (C-CDA)
3.0.0 - STU3 United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0: CCDA 3.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version. For a full list of available versions, see the Directory of published versions

Example Binary: Mental Status Section Example

This content is an example of the Mental Status Section Logical Model and is not a FHIR Resource

    
<section xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
  <templateId root="2.16.840.1.113883.10.20.22.2.56" extension="2015-08-01" />
  <!-- Mental Status Section -->
  <code code="10190-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Mental status Narrative" />
  <title>MENTAL STATUS</title>
  <text>
    <list>
      <item ID="mentalStatus1">
        <caption>Cognitive function - measured October 12, 2023</caption>
        <paragraph ID="mentalStatus1obs1">Memory finding</paragraph>
      </item>
    </list>
  </text>
  <entry>
    <organizer classCode="CLUSTER" moodCode="EVN" xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
      <!-- Mental Status Organizer-->
      <templateId root="2.16.840.1.113883.10.20.22.4.75" extension="2015-08-01" />
      <id root="a7bc1062-8649-42a0-833d-ekd65bd013c9" />
      <!-- Note this code is just SHOULD ICF or SHOULD LOINC
           Future versions of C-CDA may assign a fixed code here -->
      <code code="75275-8" 
          displayName="Cognitive function"
          codeSystem="2.16.840.1.113883.6.1"
          codeSystemName="LOINC" />
      <!-- The organizer's text element is in namespace urn:hl7-org:sdtc-->
      <sdtc:text>
        <reference value="#mentalStatus1" />
      </sdtc:text>
      <statusCode code="completed" />
      <effectiveTime>
        <low value="202310120652-0500" />
        <high value="202310120652-0500" />
      </effectiveTime>
      <component>
        <observation classCode="OBS" moodCode="EVN" xmlns="urn:hl7-org:v3">
          <!-- Mental Status Observation -->
          <templateId root="2.16.840.1.113883.10.20.22.4.74" extension="2024-05-01" />
          <id root="41cf96a8-6e2f-41b3-b210-5640ea0375a6" />
          <code code="8693-4" displayName="Mental Status"  codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
          <text>
            <reference value="#mentalStatus1obs1" />
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="202310120652-0500" />
          <value xsi:type="CD" code="106136008" displayName="Memory finding (finding)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
        </observation>
      </component>
      <!-- Additional <component> observations may be included -->
    </organizer>
  </entry>
</section>